CNN.com
November 27, 2008
By Anne Harding
Newer CT scans lack evidence that it's
more useful than older technology

Questions whether technology driving
up costs without benefit to patients


An expensive CT scan that uses
multiple X-rays to produce spectacular
3-D images of the heart can't replace
tried-and-true coronary angiography
for finding blocked blood vessels in
chest-pain patients, according to a
study in the New England Journal of
Medicine.


CT scans produce images of the heart
like this one, but they are not as
effective as an angiogram, study says.

But doctors are using the newer test --
sometimes because patients ask for it
-- despite a lack of evidence that it's
helpful, and a possibility that it might
be harmful.

"I think it's being used without clear
data of any benefit for the patient,"
says Dr. Rita Redberg, a professor at
the University of California at San
Francisco School of Medicine, who
wrote an article accompanying the
study.

The gold standard for diagnosing
heart disease is coronary angiography
(also known as an angiogram or
cardiac catheterization), in which
doctors snake a tube through the
femoral artery in the leg and up into
heart vessels to release a dye that
lights up blockages on an X-ray...
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caffeine is in your coffee
or your Excedrin?
Take a quiz.
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Heart
Most heart attack patients' cholesterol
levels did not indicate cardiac risk
By Rachel Champeau
1/12/2009

A new national study has shown that
nearly 75 percent of patients
hospitalized for a heart attack had
cholesterol levels that would indicate
they were not at high risk for a
cardiovascular event, based on
current national cholesterol guidelines.

Specifically, these patients had low-
density lipoprotein (LDL) cholesterol
levels that met current guidelines, and
close to half had LDL levels classified
in guidelines as optimal (less than 100
mg/dL).

"Almost 75 percent of heart attack
patients fell within recommended
targets for LDL cholesterol,
demonstrating that the current
guidelines may not be low enough to
cut heart attack risk in most who could
benefit," said Dr. Gregg C. Fonarow,
Eliot Corday Professor of
Cardiovascular Medicine and Science
at the David Geffen School of Medicine
at UCLA and the study's principal
investigator.

While the risk of cardiovascular events
increases substantially with LDL levels
above 40–60 mg/dL, current national
cholesterol guidelines consider LDL
levels less than 100–130 mg/dL
acceptable for many individuals. The
guidelines are thus not effectively
identifying the majority of individuals
who will develop fatal and non-fatal
cardiovascular events, according to
the study's authors.

Researchers also found that more
than half of patients hospitalized for a
heart attack had high-density
lipoprotein (HDL) cholesterol levels
characterized as poor by the national
guidelines.

Published in the January issue of the
American Heart Journal, the study
suggests that lowering guideline
targets for LDL cholesterol for those at
risk for cardiovascular disease, as well
as developing better treatments to
raise HDL cholesterol, may help
reduce the number of patients
hospitalized for heart attack in the
future.

"The study gives us new insight and
intervention ideas to help reduce the
number of heart attacks," said
Fonarow, who is also director of the
Ahmanson–UCLA Cardiomyopathy
Center.

"This is one of the first studies to
address lipid levels in patients
hospitalized for a heart attack at
hospitals across the entire country."

The research team used the national
database sponsored by the American
Heart Association's Get with the
Guidelines program. The database
includes information on patients
hospitalized for cardiovascular disease
at 541 hospitals across the country.

Researchers analyzed data from
136,905 patients hospitalized for a
heart attack nationwide between 2000
and 2006 whose lipid levels upon
hospital admission were documented.
This accounted for 59 percent of total
hospital admissions for heart attack at
participating hospitals during the study
period.

Among individuals without any prior
cardiovascular disease or diabetes,
72.1 percent had admission LDL levels
less than 130 mg/dL, which is the
current LDL cholesterol target for this
population. Thus, the vast majority of
individuals having their first heart
attack would not have been targeted
for effective preventative treatments
based on the criteria used in the
current guidelines.

The team also found that half of the
patients with a history of heart disease
had LDL cholesterol levels lower than
100 mg/dL, and 17.6 percent of
patients had LDL levels below 70
mg/dL, which are guideline targets for
LDL cholesterol in those at fair risk
and at high risk for cardiovascular
disease, respectively.

The study also showed that HDL
cholesterol, or "good cholesterol,"
levels have dropped in patients
hospitalized for heart attack over the
past few years, possibly due to
increasing rates of obesity, insulin
resistance and diabetes.

Researchers found that 54.6 percent
of patients had HDL levels below 40
mg/dL. Developing more effective
treatments to boost HDL levels may
help reduce the number of patients
hospitalized for heart attacks,
according to the authors.

"We found that less than 2 percent of
heart attack patients had both ideal
LDL and HDL cholesterol levels, so
there is room for improvement," said
Fonarow.

Fonarow said that only 59 percent of
patients in the database had their lipid
levels checked upon admission, which
should be increased, since these early
measurements can often help guide
treatment decisions.

He also noted that only 21 percent of
patients in the study were taking lipid-
lowering medications before
admission, despite almost half having
a prior history of cardiovascular
events, which would prompt treatment.

The national cholesterol guidelines are
set by the National Cholesterol
Education Program, part of the
National Heart, Lung and Blood
Institute of the National Institutes of
Health.

The study was sponsored by the Get
with the Guidelines program, which is
supported by the American Heart
Association in part through an
unrestricted education grant from the
Merck Schering Plough Partnership.

Fonarow has conducted research for
GlaxoSmithKline and Pfizer and serves
a consultant and has received
honorarium from Abbott, AstraZeneca,
GlaxoSmithKline, Merck, Pfizer and
Schering Plough companies. He is also
chair of the Get with the Guidelines
steering committee.

Other authors include: Dr. Amit
Sachdeva, Department of Medicine,
David Geffen School of Medicine at
UCLA, Los Angeles, CA; Dr.
Christopher P. Cannon, Brigham and
Women's Hospital & Harvard Medical
School, Boston, MA; Dr. Prakash C.
Deedwania, Department of Cardiology,
VA Medical Center/UCSF School of
Medicine, San Francisco, CA; Dr.
Kenneth A. LaBresh, Masspro,
Waltham, MA; Dr. Sidney C. Smith, Jr.,
University of North Carolina School of
Medicine, Chapel Hill, NC; David Dai,
MS and Dr. Adrian Hernandez, Duke
Clinical Research Institute, Durham,
NC.

UCLA is California's largest university,
with an enrollment of nearly 38,000
undergraduate and graduate students.
The UCLA College of Letters and
Science and the university's 11
professional schools feature renowned
faculty and offer more than 323
degree programs and majors. UCLA is
a national and international leader in
the breadth and quality of its
academic, research, health care,
cultural, continuing education and
athletic programs. Four alumni and five
faculty have been awarded the Nobel
Prize.